Client, counselor, prescriber

Roughly one in 10 Americans over the age of 11 takes antidepressant medication, according to data released this past fall by the Centers for Disease Control and Prevention. Antidepressants are the third most common prescription taken by Americans of all ages and the most common among Americans ages 18-44. The rise in popularity of antidepressants has been meteoric in recent decades. Since 1988, the rate of antidepressant use nationwide among all ages increased almost 400 percent.

These data, collected as part of the National Health and Nutrition Examination Surveys between 2005 and 2008, don’t surprise Dixie Meyer. In fact, they further support the message she tries to share with counselors: You need to know about the antidepressants your clients are taking.

Antidepressants, which are prescribed not just for depression but also for anxiety disorders, pain disorders, learning disabilities and more, are the medication most requested by patients, says Meyer, an assistant professor in the Department of Counseling and Family Therapy at St. Louis University and a member of the American Counseling Association. She notes that primary care physicians prescribe the majority of antidepressants. “This suggests that a large portion of our clients on antidepressants sought out the medication without knowledge of why individuals need medications, and in most cases, an expert on psychotropic medications did not prescribe the medications,” says Meyer, who teaches psychopharmacology and has been researching the topic since 2007. “While counselors are not experts on antidepressants either, counselors need to understand when their clients may need to have the medication reassessed or when the counselor may need to meet with the medication prescriber.”

Elisabeth Bennett, chair of the Department of Counselor Education at Gonzaga University, says even though counselors are not prescribing the medications, they are in a prime position to assist clients who are taking antidepressants. “Medical professionals see their psychiatric patients an average of about eight minutes each … three to four meetings per year. This is not enough time to do all the tasks they must do, let alone to build a relationship [with the patient, which] is likely the most critical element contributing to successful compliance and treatment,” says Bennett, an ACA member who also works as a counselor in private practice and has researched, taught and presented on neuropsychology and psychopharmacology.

Counselors, on the other hand, see their clients two to four times per month for an average of 50 minutes per session, Bennett says. When counselors understand what an antidepressant is meant to do and what side effects it may cause, they can better prepare their clients to follow the regimen prescribed by the medical professional, she says. Counselors can also help prepare clients to note negative side effects that might need immediate attention, note when the medication is effective or when there are breakthrough symptoms, and to otherwise gain the most benefit while experiencing the least harm.

A second set of eyes

Meyer echoes Bennett, noting that the regular interaction counselors have with their clients positions them to help with management of antidepressant medications and, in some cases, to act as the liaison between clients and the prescribing doctor. To play that role effectively, however, Meyer emphasizes that counselors must educate themselves about antidepressants. “It is important for counselors to be knowledgeable about potential side effects of antidepressants, the empirical support for antidepressants and how antidepressants work, including how they alter neurochemistry,” she says. “Counselors also need to understand the neurochemical differences of depressive symptoms and how to monitor symptom improvement when clients are taking antidepressants. This is especially important when clients think their antidepressant is not working.”

Bennett points out that the liability and authority for all elements of a medical regimen remain with the prescribing physician but says counselors can be of great value to clients by educating them about the medications and the regimens that doctors prescribe. “Often, the time limitations of the doctor make such educational sessions rushed, and the counselor can supplement at a time when the client is better able to understand, thus increasing compliance,” she says. Among the topics Bennett suggests that counselors consider discussing with these clients:

How antidepressant medications work

Why complying with the regimen is critical

How long it takes to reach therapeutic windows (when enough medication is in the bloodstream to be effective)

Potential side effects that might arise

Which side effects to be concerned about and which to endure

How to talk with the prescribing doctor about symptoms

Meyer encourages counselors to stay alert to the side effects their clients are experiencing. If the side effects appear to be getting out of hand, Meyer suggests talking with the client and perhaps encouraging him or her to ask the prescribing physician to reassess the medication or dosage. Sometimes, too many side effects mean the dosage of the antidepressant is too high, Meyer says. “Other side effects may lead a physician to prescribe an additional medication to alleviate the unwanted effect,” she says. “For example, for individuals experiencing sexual side effects [such as] lack of desire, a physician may prescribe Wellbutrin, which has been shown to help with unwanted sexual side effects.”

The counselor’s role in medication monitoring is to check in weekly with the client, Meyer says. “It is important for counselors to ask their clients if they are noticing anything unusual physically or mentally,” she says. “Counselors then need to be knowledgeable about what may be expected during the course of treatment. For example, some individuals report increased anxiety when they begin taking an antidepressant, but the anxiety subsides after a few weeks of treatment. It is important for counselors to know if certain side effects are transient.”

Sattaria Dilks, a licensed professional counselor who teaches at McNeese State University, says some antidepressants can have serious or even life-threatening side effects that counselors should be aware of and educate clients about. For instance, certain foods can have life-threatening interactions with monoamine oxidase inhibitors (MAOIs), a class of antidepressants, Dilks says. Other medications potentially can produce a life-threatening rash. Being knowledgeable of such side effects will alert counselors that a client needs to see a medical professional immediately, says Dilks, an ACA member who works in private practice as a psychiatric nurse practitioner in Lake Charles, La.

All medications have side effects, but there are two major concerns when it comes to antidepressants, Meyer says. One is increased risk for suicide among children and young adults, and the other is serotonin syndrome, in which a person’s serotonin level can increase to a potentially lethal level. Among the symptoms of serotonin syndrome are extreme anxiety, cognitive disturbances, cardiac disturbances, hyperthermia, seizures and coma, Meyer says.

Although not life-threatening, antidepressants can also have sexual side effects. As Dilks points out, clients might be more likely to disclose these side effects during regular sessions with a counselor than during a short visit with the prescribing physician.

Engaging in a conversation with clients about the relationship between physical wellness and mental wellness as it relates to antidepressants also can be worthwhile, Meyer says. “Many clients expect their antidepressant to be a ‘happy pill,’” she says. “They are disappointed, then, when they do not feel euphoric after taking the medication or assume the medication is not working because they don’t feel euphoric. Oftentimes, though, when working with these types of clients, it is important to ask about what changes they are noticing. In these situations, clients may report they are sleeping better or are not tired all the time. That is a great opportunity to discuss how those changes are positively affecting their lives. This helps clients see the big picture with how their medication may help them feel better, even if it is not an instant happy pill.”

Weighing the options

These experts also agree that counselors should know when to refer clients who aren’t taking antidepressants to a medical professional for additional help. If the client’s depression is mild to moderate and is of short duration, oftentimes, no drugs are needed, Dilks says. But if a client has a family history of depression, anxiety or bipolar disorder, has experienced multiple depressive episodes or has become suicidal, the counselor needs to refer the client for additional assistance, she says.

“Antidepressants are the most helpful for individuals suffering with the somatic symptoms of depression, anhedonia, worsened mood in the morning or concentration disturbances,” Meyer adds. “For many individuals experiencing grief, transient reactive depression or depression related to early life traumas, they may be better off processing the root of the depression with a counselor.”

With those clients who are considering antidepressant use, Meyer suggests that counselors review both the risks of taking an antidepressant and the risks of not taking an antidepressant so these individuals can make informed decisions. Counselors might also talk with clients about how diet, exercise, sleep and counseling may alter neurochemistry in a way that alleviates depressive symptoms without medication, she says.

Also worth discussing, Dilks says, is the fact that needing an antidepressant is not a failure on the part of the person taking it. “[Counselors can] help them work through that this is not a weakness [and] it’s not something they did or didn’t do,” she says. “It’s the genetic deck they got dealt.”

Meyer and Bennett point to multiple studies comparing the effectiveness of antidepressants only, counseling only and a combination of medication and counseling in treating depression. Meyer believes the results of these studies are worth discussing with clients so they will have the best information possible for reaching a decision concerning antidepressants. “Generally, the research suggests that medication only is the least helpful for treating depression,” Meyer says. “[Regarding] the best options for clients, some studies suggest counseling only is just as effective as a combination treatment. However, the majority of the research indicates the combination of counseling and medication as the best practice for depression. If the client chooses an antidepressant, it would be appropriate to address when he or she could expect to experience symptom relief, what type of symptom relief, how the medication works, the potential side effects and the expected length of treatment.”

Counselors should also be aware that antidepressants won’t work for every person or for every type of depression, Meyer says. “For example, one of the most common types of antidepressants, selective serotonin reuptake inhibitors (SSRIs), focuses on serotonin,” she says. “Yet, not all symptoms of depression are associated with serotonin.”

Effects can also vary among different populations of people, she adds. For instance, Meyer says, individuals of East Asian ethnicities typically respond better to lower dosages of antidepressants than do Caucasians. Age can also play a factor, she says. “While many children and adolescents take a variety of antidepressants, the only FDA (Food and Drug Administration)-approved antidepressant medication for use with youth is Prozac.”

If a counselor thinks a client might benefit from taking an antidepressant, it is acceptable to recommend that the client go to a doctor to be evaluated, Dilks says. However, she warns, a counselor should never tell the client to go to the doctor expecting or seeking a specific drug. It’s best to let the doctor make any recommendations, she says.

Teaming up for the client

Considering the amount of time typically spent with clients and the comparative strength of the relationship, counselors shouldn’t be shy about offering to collaborate with their clients’ prescribing doctors.

In her work as a psychiatric nurse practitioner, Dilks says she often communicates with her patients’ counselors to ensure more well-rounded care. “As a prescriber [myself], I think the counselor has a much closer relationship with the patient,” Dilks says. “They see them for a longer period of time — 50 minutes or more at a time — and generally see them more frequently. I find that if we touch base with each other periodically, we offer a more coordinated effort in providing the patient with continuity of care.”

Dilks says she collaborates with many counselors in her area, but to do so, clients must first sign a release allowing the counselor and prescriber to have ongoing contact as treatment providers. It’s not uncommon for Dilks to receive a text message or voice mail from a counselor to update her on a mutual client’s situation or to report side effects the client is experiencing related to antidepressant use.

Of course, the reality is that the counselor’s role in collaborating with the doctor, if at all, depends largely on the doctor and the client, Meyer says. “Some physicians or psychiatrists seek out the counselor’s opinion. I have been asked about client improvement and if I have suggestions for what may be best for the client. I have also discussed side effects. Some physicians may specially ask the counselor to monitor for certain side effects. Physicians may also want to know about compliance or complaints that the client has,” she says. “I find that often the role of the counselor is dependent upon the prescribing physician. This may include a meeting and then follow-up phone calls, or it may mean discussing with the client what he or she plans to share in his or her meeting with the prescribing physician.”

A counselor’s thoughts and observations can be especially helpful when the prescribing physician is a general practitioner, Bennett says. “Most general practitioners have not had many psych courses or extensive psych training. They tend to do very brief rotations through psychiatry during their third year of med school, during which time they are only briefly exposed to psychopathology and rarely exposed at all to what counselors can and do facilitate. They usually know that there is something ‘mental’ going on but not what to do with it. They medicate the symptoms as best they can and hope the patient will feel better and/or complain less. Counselors can be of great help to the medical professional but need to be sure to respect the professional and his or her role as the medical expert.”

Taking a collaborative approach can prove beneficial to both the counselor’s and the doctor’s practice, Meyer says. “Many physicians are looking for counselors for referrals. Oftentimes, a referral base can be created by counselors just through those physicians who are seeking out the counselor’s opinion. If asked to meet with a physician, this could be a great opportunity to leave some cards. The reverse is also true. Many counselors are looking for physicians for client referrals. From this, a mutually beneficial relationship could be created.”

But even more important, Dilks says, collaboration benefits clients. “All of us want our patients/clients to have the best care possible, and that is incredibly more efficient when we all work together — therapist, prescriber and patient.”

Antidepressants and bipolar disorder

When working with clients who are taking antidepressants, Dixie Meyer, an assistant professor in the Department of Counseling and Family Therapy at St. Louis University, is careful to assess for Bipolar Disorder I and II. Many people with bipolar disorder don’t seek counseling for manic or hypomanic episodes, Meyer explains, but they might seek counseling or medication for depression. For that reason, she advises counselors to be on the lookout for undiagnosed bipolar disorder.

It is especially important to be cognizant of undiagnosed bipolar disorder because the use of antidepressants may precipitate a manic episode, says Meyer, who teaches psychopharmacology at St. Louis University and has been researching the subject for five years. “Caution should also be utilized when working with individuals who have a family history because they may be at risk for bipolar disorder,” Meyer says. “When counseling clients who are on antidepressants, we address how they are feeling after using the antidepressants. If clients report irritability, racing thoughts or distraction, I also look for other indicators of mania or hypomania such as increased motor behavior or rapid speech. If symptoms of mania or hypomania are observed, I recommend the client meet with a psychiatrist about treatment with a mood stabilizer.”